<%@ Page Language="C#" AutoEventWireup="true" MasterPageFile="~/FeaturedMember.master" CodeFile="patient_registration.aspx.cs" Inherits="patient_registration" Title="Patient Registration - FindaDoc.com" %>

<%@ Register Assembly="Manager" Namespace="SiteManager" TagPrefix="cc1" %>
<%@ MasterType VirtualPath="~/FeaturedMember.master" %>
<asp:Content ContentPlaceHolderID="MainTable" runat="server">
    <%--<div class="left-side fl"><h2>Already registered? <a href="<%=Session["strHttps"]%>dentist/dentistlogin.aspx" style="text-decoration:none;color:#FF4403">Login</a></h2>
   </div>--%><!---/ Left wrapper -->

    <!--**Content 1 Starts Here**-->



    <!--**Content 1 Starts Here**-->
    <div class="form_rgist">
        <div id="TabbedPanels1" class="TabbedPanels">
            <ul class="TabbedPanelsTabGroup">
                <li class="TabbedPanelsTab " tabindex="0"><a href="<%=Session["strHttps"]%>Doctor/AccessProfile.aspx" style="text-decoration: none;">DOCTOR REGISTRATION</a></li>
                <li class="TabbedPanelsTab " tabindex="0"><a href="<%=Session["strHttps"]%>Dentist/DentistAccessProfile.aspx" style="text-decoration: none">DENTIST REGISTRATION</a></li>
                <li class="TabbedPanelsTab TabbedPanelsTabSelected" tabindex="0">PATIENT REGISTRATION</li>
            </ul>
            <div class="TabbedPanelsContentGroup">
                <!--**Content 1 Starts Here**-->
                <div class="TabbedPanelsContent">
                    <div class="find_doc">
                        <div style="text-align: center" id="trError" runat="server">
                            <asp:BulletedList ID="errorlist" runat="server" ForeColor="Red">
                            </asp:BulletedList>
                        </div>
                        <div style="width: 100%;">
                            <table width="95%" border="0" align="center" cellpadding="0" cellspacing="0">
                                <tr>
                                    <td style="height: 20px; width: 516px;" align="left" valign="top" class="blue-hd">Personal information:
                                    </td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <img src="<%=Session["strHttps"].ToString() %>images/dotted-line.gif" alt="" width="514" height="1" /></td>
                                </tr>
                                <tr>
                                    <td align="center" style="width: 516px; padding: 0px 0px 0px 20px;">
                                        <table width="97%" border="0" align="left" cellpadding="0" cellspacing="0">
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                            </tr>
                                            <tr>
                                                <td colspan="" class="txt12" align="left" style="height: 24px">Email<span class="red-text">*</span> :&nbsp; </td>
                                                <td></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" align="left">
                                                    <asp:TextBox ID="txtemailid" runat="server" CssClass="design" MaxLength="31" Width="170px"></asp:TextBox>
                                                    &nbsp;&nbsp; &nbsp;<span class="small-text">(You will log-in with this email-id as your username.)</span></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                            </tr>
                                            <tr>
                                                <td style="width: 70px; height:24px" align="left" class="txt12">Password<span class="red-text">*</span> :</td>
                                                <td style="width: 287px" align="left" class="txt12">Retype Password<span class="red-text">*</span> :</td>
                                            </tr>
                                            <tr>
                                                <td align="left">
                                                    <asp:TextBox ID="txtpassword" runat="server" CssClass="design" MaxLength="15" Width="170px" TextMode="Password"></asp:TextBox></td>
                                                <td align="left">
                                                    <asp:TextBox ID="txtrepassword" runat="server" CssClass="design" MaxLength="15" Width="170px" TextMode="Password"></asp:TextBox></td>
                                            </tr>
                                            <tr>
                                                <td class="small-text" align="left" colspan="2">(Passwords are case-sensitive)</td>
                                            </tr>
                                            <tr>
                                                <td style="height: 20px" colspan="2">&nbsp;</td>
                                            </tr>
                                        </table>
                                    </td>
                                </tr>
                                <tr>
                                    <td style="height: 20px; width: 516px;" align="left" valign="top" class="blue-hd">User information:</td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <img src="<%=Session["strHttps"].ToString() %>images/dotted-line.gif" alt="" width="514" height="1" /></td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <table width="97%" border="0" align="center" cellpadding="0" cellspacing="0">
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                            </tr>
                                            <tr>
                                                <td style="width: 40px; height: 24px;" class="txt12">Security Question<span class="red-text">*</span>  : </td>
                                                <td style="width: 238px; height: 24px;" class="txt12">Secret Answer<span class="red-text">*</span>  : </td>
                                            </tr>
                                            <tr>
                                                <td style="width: 150px; height: 21px;">
                                                    <div class="styled-select" style="width: 150px">
                                                        <asp:DropDownList ID="combosecquestion" runat="server" Width="200px">
                                                        </asp:DropDownList>
                                                    </div>
                                                </td>
                                                <td style="width: 238px; height: 21px;">
                                                    <asp:TextBox ID="txtsecanswer" runat="server" CssClass="design" MaxLength="31" Width="170px"></asp:TextBox></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height:24px" class="txt12">Nickname<span class="red-text">*</span> :</td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">
                                                    <asp:TextBox ID="txtnickname" runat="server" CssClass="design" MaxLength="20" Width="160px"></asp:TextBox>
                                                    &nbsp;&nbsp;<span class="small-text">(This will be your public name on this site.)</span></td>
                                            </tr>
                                            <tr>
                                                <td style="height: 20px" colspan="2">&nbsp;</td>
                                            </tr>
                                        </table>
                                    </td>
                                </tr>
                                <tr>
                                    <td style="height: 20px; width: 516px;" align="left" valign="top" class="blue-hd">General information:</td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <img src="<%=Session["strHttps"].ToString() %>images/dotted-line.gif" alt="" width="514" height="1" /></td>
                                </tr>
                                <tr>
                                    <td align="left">
                                        <table width="97%" border="0" align="center" cellpadding="0" cellspacing="0">
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" style="width: 130px; height:24px" >First Name<span class="red-text" style="color: #ff0000">*</span> :</td>
                                                <td class="txt12">Middle &nbsp;Name :</td>
                                                <td class="txt12">Last Name<span class="red-text" style="color: #ff0000; height:24px">*</span> :</td>
                                            </tr>
                                            <tr>
                                                <td style="width: 130px; height: 21px;">
                                                    <asp:TextBox ID="txtfname" runat="server" CssClass="design" MaxLength="31" Width="160px"></asp:TextBox>
                                                </td>
                                                <td style="height: 21px">
                                                    <asp:TextBox ID="txtmname" runat="server" CssClass="design" MaxLength="31" Width="160px"></asp:TextBox></td>
                                                <td style="height: 21px">
                                                    <asp:TextBox ID="txtlname" runat="server" CssClass="design" MaxLength="31" Width="160px"></asp:TextBox></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td style="width: 130px; height: 24px" class="txt12">Year of Birth <span class="red-text" style="color: #ff0000">*</span>:</td>
                                                <td style="width: 287px; height: 24px" class="txt12">Gender<span class="red-text" style="color: #ff0000">*</span> :</td>
                                                <td style="width: 287px; height: 15px;"></td>
                                            </tr>
                                            <tr>
                                                <td style="width: 130px; height: 21px;">
                                                   <div class="styled-select" style="width: 160px">
                                                         <asp:DropDownList ID="ddlBirthYear" runat="server" style="width: 180px">
                                                    </asp:DropDownList></div>
                                                    <!--//Change 04/24/2006 - Birth date changed to birth year
                            <asp:TextBox ID="txtbirthdate" runat="server" CssClass="design" MaxLength="31" Width="120px"></asp:TextBox>
                            <a href="javascript:void(0)" onclick="if(self.gfPop)gfPop.fPopCalendar(document.aspnetForm.<%=txtbirthdate.ClientID %>);return false;"><img class="PopcalTrigger" align="middle" src="../Images/calbtn.gif" width="34" height="22" border="0" alt=""/></a>-->
                                                </td>
                                                <td style="height: 21px">
                                                    <asp:RadioButton ID="rad_gender" runat="server" Text="Male" Checked="True" GroupName="selgender" />
                                                    <asp:RadioButton ID="rad_gender1" runat="server" Text="Female" GroupName="selgender" />
                                                </td>
                                                <td style="height: 21px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" colspan="2"><span><span style="color: #000000">Address1</span><span style="color: #000000; height:24px"> :</span></span></td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height: 15px">
                                                    <asp:TextBox ID="txtaddress1" runat="server" CssClass="design" MaxLength="31" Width="224px"></asp:TextBox></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height: 15px"></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" colspan="2" style="height: 24px">Address2<span style="color: #000000">
                                    :</span></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height: 15px">
                                                    <asp:TextBox ID="txtaddress2" runat="server" CssClass="design" MaxLength="31" Width="224px"></asp:TextBox></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height: 15px"></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" style="width: 130px; height:24px">City : </td>
                                                <td class="txt12">Zip / Postal Code<span class="red-text" style="color: #ff0000">*</span> :</td>
                                                <td></td>
                                            </tr>
                                            <tr>
                                                <td colspan="1" style="height: 15px">
                                                    <asp:TextBox ID="txtcity" runat="server" CssClass="design" MaxLength="31" Width="160px"></asp:TextBox>
                                                </td>
                                                <td>
                                                    <asp:TextBox ID="txtzipcode" runat="server" CssClass="design" MaxLength="10" Width="160px"></asp:TextBox></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" style="height: 15px"></td>
                                                <td colspan="1" style="height: 15px"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" style="width: 434px; height:24px">State<span class="red-text" style="color: #ff0000">*</span> : 
                            
                                                </td>
                                                <td class="txt12" style="height:24px">Country<span class="red-text" style="color: #ff0000">*</span> :</td>
                                                <td></td>
                                            </tr>
                                            <tr>
                                                <td style="width: 130px">
                                                    <asp:TextBox ID="txtstate" runat="server" CssClass="design" MaxLength="31" Width="160px"></asp:TextBox></td>
                                                <td>
                                                    <div class="styled-select" style="width: 160px">
                                                        <asp:DropDownList ID="combocountry" runat="server" Width="180px"></asp:DropDownList>
                                                    </div>
                                                    <%--                            <asp:DropDownList ID="combocountry" runat="server" CssClass="small-text" Width="140px">
                                <asp:ListItem>Select</asp:ListItem>
                                <asp:ListItem>Plan1</asp:ListItem>
                                <asp:ListItem>Plan2</asp:ListItem>
                                <asp:ListItem>Plan3</asp:ListItem>
                            </asp:DropDownList>--%></td>
                                                <td></td>
                                            </tr>
                                            <tr>
                                                <td style="width: 130px">&nbsp;</td>
                                                <td>&nbsp;</td>
                                                <td></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2" class="txt12" style="height: 24px">Insurance : </td>
                                                <td colspan="1" style="height: 13px"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">
                                                    <div class="styled-select" style="width: 160px">
                                                        <asp:DropDownList ID="combohplan" runat="server" Width="180px"></asp:DropDownList>
                                                    </div>
                                                </td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td colspan="2">&nbsp;</td>
                                                <td colspan="1"></td>
                                            </tr>
                                            <tr>
                                                <td class="txt12" valign="top" style="height:24px">Enter the code shown<span style="color: red">*</span> :</td>
                                                <td></td>
                                                
                                            </tr>
                                            <tr>
                                            <td  style=" width:40px">
                                                    <cc1:CaptchaControl ID="captcha" runat="server" CaptchaHeight="40"  CaptchaBackgroundNoise="Medium" CaptchaFontWarping="None" CaptchaLineNoise="Low" LayoutStyle="Vertical" Text="" ToolTip="" />
                                                    <span class="small-text" style="font-size: 7pt">This helps prevent automated registrations.</span></td>
                                                    <td></td>
                                            </tr>
                                        </table>
                                    </td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <br />
                                        <br />

                                        <img src="<%=Session["strHttps"].ToString() %>images/dotted-line.gif" alt="" width="514" height="1" /></td>
                                </tr>
                                <!--<tr>
                    <td align="left" style="width: 516px">&nbsp;g</td>
                  </tr>-->
                                <tr>
                                    <td align="left" style="width: 516px; height: 100px;">
                                        <table width="100%" border="0" cellspacing="0" cellpadding="0">
                                            <tr>
                                                <td style="width: 95%" valign="top" colspan="2">

                                                    <br />

                                                    <asp:CheckBox ID="chkoffer" CssClass="txt12" runat="server" Text="Check this box for free offers, coupons, and medical insights from health-friendly sponsors at FindaDoc " Height="16px" /></td>
                                            </tr>
                                            <tr>
                                              
                                                <td style="height: 100px" colspan="2" valign="top" class="txt12">
                                                    <br />
                                                    <asp:CheckBox ID="chkagree" runat="server" Text="" />&nbsp;
                                                          I have read and agree to abide by the FindaDoc <a href="<%=Session["strHttp"]%>Terms.aspx">Terms and Conditions</a> and FindaDoc <a href="<%=Session["strHttp"]%>PrivacyPolicy.aspx">Privacy Policy</a>
                                                    <br />
                                                </td>
                                            </tr>
                                            <tr>
                                                <td style="height: 40px" align="center">
                                                    <asp:Button ID="btnSubmit" runat="server" CssClass="buttonclass" Text="Submit" OnClick="btnSubmit_Click" />&nbsp;&nbsp;&nbsp;&nbsp;<asp:Button
                                                        ID="ImageButton2" runat="server" CssClass="buttonclass" Text="Cancel" OnClick="ImageButton2_Click" Style="margin-left: 20px" /></td>
                                            </tr>
                                        </table>
                                    </td>
                                </tr>
                                <tr>
                                    <td align="left" style="width: 516px">
                                        <img src="<%=Session["strHttps"].ToString() %>images/spacer.gif" alt="" width="8" height="8" /></td>
                                </tr>
                            </table>
                        </div>


                    </div>
                </div>
            </div>
        </div>
    </div>

</asp:Content>
<asp:Content runat="server" ContentPlaceHolderID="ScriptContent">

    <!--place your script here-->
    <iframe width="174" height="189" name="gToday:normal:agenda.js" id="gToday:normal:agenda.js" src="../JScript/ipopeng.htm" scrolling="no" frameborder="0" style="visibility: visible; z-index: 999; position: absolute; top: -500px; left: -500px;"></iframe>
    <script>

        //<![CDATA[

        //You should create the validator only after the definition of the HTML form
        function checkme() {
            missinginfo = "";

            if (!document.getElementById("<%=chkagree.ClientID %>").checked) {
                missinginfo += "\n - You must agree to the terms";
            }
            if (missinginfo != "") {
                missinginfo = "__________________________________\n" +
                "Required information is missing: \n" +
                missinginfo + "\n__________________________________" +
                "\nPlease complete and resubmit.";
                alert(missinginfo);
                return false;
            }
            else {
                return true;
            }
        }


        var frmvalidator = new Validator("aspnetForm", "<%=btnSubmit.ClientID%>", "checkme()");

        frmvalidator.addValidation("<%=txtemailid.ClientID%>", "req", "Please Enter Email-Id.");
        frmvalidator.addValidation("<%=txtpassword.ClientID %>", "req", "Please Enter password.");
        frmvalidator.addValidation("<%=txtpassword.ClientID %>", "minlen=6", "Please Enter password.");
        frmvalidator.addValidation("<%=txtrepassword.ClientID %>", "req", "Please Retype your password.");
        frmvalidator.addValidation("<%=txtnickname.ClientID %>", "req", "Please Enter your Nick Name.");
        frmvalidator.addValidation("<%=txtfname.ClientID %>", "req", "Please Enter your first Name.");
        frmvalidator.addValidation("<%=txtlname.ClientID %>", "req", "Please Enter your last Name.");
        //Change 04/24/2006 - Address Not mandatory, birthdate changed to birth year
        //frmvalidator.addValidation("<%=txtbirthdate.ClientID %>","req","Please Enter Birth date.");
        //frmvalidator.addValidation("<%=txtaddress1.ClientID %>","req","Please Enter your address.");	
        //frmvalidator.addValidation("<%=txtcity.ClientID %>","req","Please Enter your City.");	
        //End Change 04/24/2006
        frmvalidator.addValidation("<%=ddlBirthYear.ClientID %>", "dontselect=0", "Please select birth year.");
        frmvalidator.addValidation("<%=txtzipcode.ClientID %>", "req", "Please Enter your Zip Code.");
        frmvalidator.addValidation("<%=txtstate.ClientID %>", "req", "Please Enter your State.");
        frmvalidator.addValidation("<%=txtrepassword.ClientID %>", "req", "Please Retype your password.");
        frmvalidator.addValidation("<%=combocountry.ClientID %>", "dontselect=0", "Please Select Country");
        //Change 04/24/2006 - Health plan Not mandatory 
        //frmvalidator.addValidation("<%=combohplan.ClientID %>","dontselect=0","Please Select Health Care Plan");
        //End Change 04/24/2006
        frmvalidator.addValidation("<%=txtaddress1.ClientID %>", "maxlength=100", "Address Maximum Length is Only 100 Characters");
        //Change 04/24/2006 - City Not mandatory 
        //frmvalidator.addValidation("<%=txtcity.ClientID %>","alpha","Please enter Correct City Name.");
        //End Change 04/24/2006
        frmvalidator.addValidation("<%=txtemailid.ClientID %>", "email");
        frmvalidator.addValidation("<%=txtrepassword.ClientID %>", "compare", "<%=txtpassword.ClientID %>|Passwords does not match.");
        frmvalidator.addValidation("<%=combosecquestion.ClientID %>", "dontselect=0", "Please Select Security Question");
        frmvalidator.addValidation("<%=txtsecanswer.ClientID %>", "req", "Please Enter your secret answer.");

        //]]>

    </script>
</asp:Content>
